Advocacy

The ACP Advocate Blog

by Bob Doherty

Monday, June 18, 2012

What we Lose if ObamaCare Goes

What will a Supreme Court ruling against the Affordable Care Act mean for health care? The answer, actually, is pretty simple: veterans, seniors, people with pre-existing conditions, primary care doctors, people who buy coverage from the individual insurance market, children and adults with pre-existing conditions, and of course the uninsured, are among the tens of millions of Americans will lose out if the ACA goes away.

For the past several weeks, I have been tweeting (under the hash tag #WhatWeLOSEifObamacareGoes) about who will lose out, and what they will lose, if the ACA is overturned. Here is a partial list, drawn from credible studies and news reports:

40 MILLION seniors on Medicare will spend an average of $20,000 more out of their own pockets for medical care and prescriptions.

The 47% of us who do not get needed screening tests and wellness examinations will face new barriers because insurers no longer will be required to cover preventive services at no cost to the patient.

Many more of us will end up having to get care from over-crowded emergency rooms.

And, of course, 32 MILLION uninsured persons—many of them from the working poor—will lose access to affordable health insurance coverage.

Elimination of the ACA will also have a negative impact on the economy in many states: California alone will lose100,000 JOBS and 1.4 billion in ECONOMIC OUTPUT.

But I think the greatest thing we will lose is the chance to finally, after a century of trying and failing, do the right thing and ensure that all of us, no matter where we live or work or how much we earn or how healthy or unhealthy we are, will have access to affordable health insurance coverage. If the ACA goes away, I see no chance that Congress will enact a replacement plan to ensure coverage for all, at least not for another decade or so. And that will be to our lasting shame as a country.

Today’s questions: Who do you think we lose the most if the ACA goes away? And if we lose our chance now to provide coverage to nearly all Americans, when do you think Congress will take the issue up again?

7 Comments
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We continue to proceed with a failed system. It will be several years before congress touchs health care again.

There are some interesting developments in the private sector outside of the ACA. Last Thursday the Senate Finance Committee had a hearing on Medicare physician payment with success stories in the private sector. 4 major insurers showed that by giving quality bonuses to primary care providers with some shared risk for total cost of care that health care costs can be curbed by reducing unnecessary procedures, hospitalizations and ER visit. Hmmm, where have I heard this before? They also mentioned that the biggest bang for the buck is keeping the 10-20% of the population with chronic illness who consume 65-80% of health care dollars well.

Skyrocketing health care costs are hitting the ceiling for tolerance and the private sector will do what it takes to bend the cost curve. As shown time and again a primary care provider (including the endocrinologists taking care of diabetics and ID docs taking care of HIV illness) taking full responsibility for a patient with chronic illness can improve health outcomes and reduce cost of care.

Again, it's unclear whether the entire bill will fail if the unpopular (and constitutionally questionable) individual mandate is struck down. As before, this blog premises "the sky is falling".

I don't think that there is any reason that popular features of the ACA (such as no pre-existing conditions), can't be put into effect by a Congress filled by either party.

What will we "lose", if the whole bill goes under?-- The Independent Payment Advisory Board, stuffed with political appointees, wielding rationing power over Medicare payments to doctors-- the $575 billion reduction in pay to Medicare providers (the SGR on steroids!)-- More than 100 new boards & agencies to lock in government control of the health sector.-- To avoid govt-mandated plans for employees or federal fines, small businesses may drop job-based coverage and workers will flood into taxpayer-subsidized insurance.-- 20 new taxes ($500 billion) on everything from medical innovation, health insurance and even sale of your home.-- Political control of medical practice: "Value-based" payments, quality reporting requirements and comparative-effectiveness boards dictating patient care decisions. Do you all like pre-auth's and "stepped care" now? Just wait.

I've been keeping up with the blog, even though I haven't had much to say for a while. Emotions have run a little hot of late, but the stakes do justify strong feelings. Bob, your one sided support and overt pulling on the strings of a bleeding heart are a valid point of view. I believe, however, that the bureaucratic realities that you are promoting (the exchanges, the medical homes, the ACO's) are truly a disease worse than reformed fee for service. The small/large dichotomy topic certainly hit on this. If there is validity to our efforts (which I certainly believe there is), than how can we believe that the anti-volume drive will really work? Is there churning out there? I am sure there is. Is there much more hard effort, with doctors struggling to do well by patients who run the gamut from compulsively healthy to indifferent to fiercely independent to insightfully skeptical to outright suspicious? You bet. Will computers help me sort out who's who and focus follow up? Maybe, but not if I am a team that is so large that I don't really know who is who.

You have supported a policy that demeans small practices. Your request that we rise to the occasion, submit to more rules, be appreciative of Medicare raises that fail to approach a true change in business realities, and put up with prescriptions that can cost 10-20 years worth of our services, is hard to swallow.

I will stay flexible, as one day I may not have to choice to work hard, answer my calls, and sacrifice hours from my family to feel I am doing right by my patients. The incentive to work hard is hardly the problem with modern medicine. The cost structures that have evolved to support big entities while squeezing the front-line care givers are. The ACA did not tackle these. It simply creates structures that can be painted as you have, but that do not add sustainability to the equation. For profit insurance with resources to flood us with commercials, a brand-generic landscape that keeps legions of lawyers busy and makes sane prescribing impossible, new technologies that come in at extreme costs and stay that way. These are left to be addressed by IPAB's and the like. Wow, what a deal.

I'm not for predicting, but a return to square one may not be as bad as suffering through more years of bureaucratic transition after which independent physician practices have been scrubbed from the landscape.

There are also an interesting assortment of Constitutional questions raised by the ACA and the way it was passed as highlighted by a CATO post I cannot find. One major issue with the ACA is the prohibition that Congress cannot change any part of the law. The Supreme Court has found that this is not allowed and that Congress can change and amend any law as they see fit.

On a personal note I have found the clumsy attempts at intimidating the Supreme Court by the Administration to be despicable. We are a country of laws and while it is nice to speak of what is “fair” ultimately it is the rule of law that maintains our civil society.

We have many problems that need to be addressed in the short run, but what is fair for one group often comes at the expense of another group. This is why we need well thought out laws that benefit the most people, while still remaining within the confines of out legal structure.

Lets face it Bob. The ACP participated in the making of a rotting sausage during the ACA enactment process and is now at all cost defending its legitimacy. The points made by the other authors say it all. This country is very resilient and we will figure it out. The canary in the coalmine which is the samll solo internist practice, which was the building blocks on which the ACP was built is dying. Rest assured that with that death the ACP will be weakened tremendously.

I appreciate your thoughts. However, realize that even if the individual mandate is scrapped value purchasing that include ACOs and fines for readmissions have come to stay.have you never thought of scrapping employer based insurances and giving the tax benefits to the individuals to purchase their care. We allow it for mortgage insurance. Would you allow the Board of ACP to select your home?

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